Mortality estimates by age and sex among persons living with HIV after ART initiation in Zambia using electronic medical records supplemented with tracing a sample of lost patients: A cohort study (original) (raw)
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PLoS medicine, 2018
Survival represents the single most important indicator of successful HIV treatment. Routine monitoring fails to capture most deaths. As a result, both regional assessments of the impact of HIV services and identification of hotspots for improvement efforts are limited. We sought to assess true mortality on treatment, characterize the extent under-reporting of mortality in routine health information systems in Zambia, and identify drivers of mortality across sites and over time using a multistage, regionally representative sampling approach. We enumerated all HIV infected adults on antiretroviral therapy (ART) who visited any one of 64 facilities across 4 provinces in Zambia during the 24-month period from 1 August 2013 to 31 July 2015. We identified a probability sample of patients who were lost to follow-up through selecting facilities probability proportional to size and then a simple random sample of lost patients. Outcomes among patients lost to follow-up were incorporated into...
Tropical Medicine & International Health, 2010
Objective To date, data regarding the determinants of mortality in HIV-infected patients starting antiretroviral therapy (ART) in Africa have been primarily derived from routine clinical care settings practicing the public health approach. Losses to follow-up, however, are high in these settings and may lead to bias in understanding the determinants of mortality.Methods We evaluated HIV-infected adults initiating ART between January 1, 2004 and September 30th, 2007 in an ART clinic in southwestern Uganda. Clinical and demographic characteristics were obtained through routine clinical care. In evaluating determinants of mortality, a ‘naïve’ analysis used only deaths known through routine processes. A ‘sample-corrected’ approach incorporated, through probability weights, outcomes from a representative sample of patients lost to follow-up whose vital status was ascertained through tracking in the community.Results In 3,628 patients followed for up to 3.75 years after ART initiation, the ‘naïve’ approach identified male sex and lower pre-ART CD4 count as independent determinants of mortality. The ‘sample-corrected’ approach found lower pre-ART CD4 count, older age, lower weight and calendar year of ART initiation, but not male sex, to be independent determinants of mortality.Conclusions Analyses to identify determinants of mortality in HIV-infected patients on ART in Africa that do not account for losses to follow-up can identify spurious associations and miss actual relationships – both with the potential to mislead public health efforts. A sampling-based approach to account for losses to follow-up represents a feasible and potentially scalable method to strengthen the evidence available for implementation of ART delivery in Africa.
2013
Evaluation of differences between human immunodeficiency virus (HIV)-infected men and women in antiretroviral therapy (ART) enrollment characteristics and outcomes might identify opportunities to improve ART program patient outcomes and prevention impact. During September 2008-February 2012, retrospective cohort studies to estimate attrition of enrollees (i.e., from death, stopping ART, or loss to follow-up) at 6-month intervals after ART initiation were completed among samples of adult men and women (defined as aged ≥15 years or aged ≥18 years) who initiated ART during 2004-2010 in six African countries: Côte d'Ivoire in western Africa; Swaziland, Mozambique, and Zambia in southern Africa; and Uganda and Tanzania in eastern Africa. Records for 13,175 ART enrollees were analyzed; sample sizes among the six countries ranged from 1,457 to 3,682. In each country, women comprised 61%-67% of ART enrollees. Median CD4 count range was 119-141 cells/µL for men and 137-161 cells/µL for w...
The lancet HIV, 2015
Mortality after initiation of antiretroviral treatment (ART) among HIV-infected patients in resource limited settings is a critical measure of the effectiveness and comparative effectiveness of the global public health response. Unknown outcomes due to high loss to follow-up (LTFU) preclude accurate accounting of deaths and limit our understanding of effectiveness. We evaluated in HIV-infected adults on ART in 14 clinics in five settings in Kenya, Uganda and Tanzania using a sampling-based approach in which we intensively traced a random sample of lost patients (> 90 days late for last scheduled visit) and incorporated their vital status outcomes into analyses of the entire clinic population through probability-weighted survival analyses. We followed 34,277 adults on ART from Mbarara and Kampala, Uganda; Eldoret and Kisumu, Kenya; and Morogoro, Tanzania. The median age was 35 years, 34% were men, and median pre-therapy CD4 count was 154 cells/μl. Overall 5,780 (17%) were LTFU, 99...
Malawi Medical Journal, 2010
Background There is currently a dearth of knowledge on gender differences in mortality among patients on ART in Africa. Methods Using data from the national ART monitoring and evaluation system, a survival analysis of all healthcare workers, teachers, and police/army personnel who accessed ART in Malawi by June, September and December 2006 respectively, was undertaken. Gender differences in survival were analysed using Kaplan-Meier estimates and rate ratios were derived from Poisson regression adjusting for confounding. Results 4670 ART patients (49.8% female) were followed up for a median of 8.7 months after starting ART. Probability of death was significantly higher for men than women (p<0.001). Controlling for age, WHO clinical stage and occupation, men experienced nearly 2 times the mortality of women RR 1.90 [95% CI: 1.57-2.29]. A higher proportion of men initiated ART in WHO stage 4 (p<0.001). Conclusion Among healthcare workers, teachers, police/army personnel, men have higher mortality on ART than women. Possible reasons are unclear but could be biological or because men present for ART at a later clinical stage or have poorer adherence to therapy. Improving early access to ART may reduce mortality, especially among men. A gender difference in adherence to therapy needs further investigation.
Background: We aimed to assess the relationship between gender and survival among adult patients newly enrolled on antiretroviral therapy (ART) in Uganda. We also specifically examined the role of antenatal services in favoring women’s access to HIV care. Methods: From an observational cohort study, we assessed survival and used logistic regression and differences in means to compare men and women who did not access care through antenatal services. Differences were assessed on measures of disease progression (WHO stage and CD4 count) and demographic (age, marital status, and education), behavioral (sexual activity, disclosure to partner, and testing), and clinical variables (hepatitis B and C, syphilis, malaria, and anemia). A mediational analysis that considered gender as the initial variable, time to death as the outcome, initial CD4 count as the mediator, and age as a covariate was performed using an accelerated failure time model with a Weibull distribution. Results: Between 2004 and 2011, a total of 4775 patients initiated ART, and after exclusions 4537 (93.2%) were included in analysis. Men initiating ART were more likely to have a WHO disease stage III or IV (odds ratio: 1.46, 95% confidence interval [CI]: 1.29–1.66), and lower CD4 cell counts compared to women (median baseline CD4 124 cells/mm3, interquartile range [IQR]: 43–205 versus 147 cells/mm3, IQR: 68–212, P-value , 0.0001). Men were at an increased risk of death compared to women (hazard ratio: 1.38, 95% CI: 1.03–1.83). Baseline CD4 cell counts accounted for 43% of the increased risk of death in men (95% CI: 22%–113%). Access to care via antenatal services did not explain differences in outcomes. Conclusion: In this cohort there is a marked increase in risk of mortality for men and approximately half of it can be attributed to their later engagement in care. More effort is required to engage men in care in a timely manner. Keywords: HIV, antiretroviral therapy, gender, Uganda, antenatal care, mortality
Ethiopian Medical Journal, 2019
Aim/PurposeIn Ethiopia data concerning the influence of gender on mortality and loss to follow-up are controversial. Our study is intended to further investigate gender-related differences in antiretroviral therapy (ART) outcomes in Tigray (Ethiopia).Methods We used data from the “Cohort of African people Starting Antiretroviral therapy’ (CASA) project, a prospective study of a cohort of HIV-positive patients who started ART in Tigray. The study population included HIV-positive patients starting ART between January 2013 and December 2015. Baseline characteristics were compared between men and women using Kruskal Wallis t-test and Chi-squared test. Kaplan-Meier method was used to estimate the probability of mortality and loss to follow-up for men and women. Univariate and multivariate Cox Proportional Hazards models were used to compare differences in ART outcomes by gender.ResultsThe study population included 1622 patients, 1003 (61.84%) women and 619 (38.16) men. Median follow-up t...